Understanding Claim Results and Re-Checking a Claim

 The Claim Details page

The header shows the patient's name, gender and age, and insurance company, along with these actions: Delete, Edit, Verify, Merge With Patient, and Re-check Claim.

There are three tabs: Claim Details, Request Details, and Comments.

Claim Details tab

Summary

The top of the tab totals all the claims listed below it:

• Percentage collected

• Total billed

• Total collected

• Average days to pay

• Total claims

Claim rows

If the payer returns more than one claim, each appears as its own row with:

• Claim ID

• Claim amount

• Payment amount

• Start and end dates

• Check number and check date

• Last request date

• Status message

Charge details

Click a Claim ID to open the detail view for that one claim. It shows the charge amount, payment amount, procedure code, quantity, start and end dates, and the payer's status codes with descriptions. For example, a status code might read "Processed according to contract provisions" or "Finalized/Payment - The claim/line has been paid."

Returned results come directly from the payer and can't be edited.

Request Details tab

Shows what was submitted for the request: name, date of birth, gender, claim status, insurance company, member ID, facility, and the claim start and end dates. It also shows who created the request, when it was created, and who last updated it and when.

Comments tab

Use comments to collaborate with your team on a claim. You can:

• Add internal comments

• Tag a teammate with an @ mention

• Upload an image, such as a photo of an insurance card

Edit

Edit changes the request details, such as patient information or search criteria. It does not change the claim results the payer returned. To get updated results, use Re-check Claim.

Re-check a claim

Use Re-check Claim to ask the payer for the latest status, for example when a claim was still pending the last time you checked.

1. Open the claim.

1. Click Re-check Claim.

1. Review the search criteria. They are copied from the original request, and you can edit them before submitting.

1. Submit the request.

A re-check sends a new request to the payer and uses a new claims credit. The new result may appear as its own claim record in your Claims list.

Understanding status messages

Status messages and codes come from the payer, so wording varies. Common ones include:

• Paid or finalized: The payer processed the claim and made payment.

• Processed according to contract provisions: The payer applied your contract terms.

• Unable to return status: The payer could not find the claim with the information submitted. Check the patient details, payer, and dates.

• Missing or invalid information: A detail in the request didn't match what the payer expected. Correct it and re-check.

• Cannot provide status electronically: The payer doesn't support electronic claim status checks. Contact the payer directly.

If you're unsure what a message means, contact Support and include the claim ID and the date you ran the request.